Content Section
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Payment Allowances for the Influenza Virus Vaccine (CPT 90655, 90656, 90657, and 90658) and the Pneumococcal Vaccine (CPT 90732) When Payment Is Based on 95 Percent of the Average Wholesale Price (AWP)
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MLN Matters. . .Information for Medicare Providers
(Issued by the Centers for Medicare & Medicaid Services)
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Provider Types Affected
Physicians, non-physician practitioners, providers, and suppliers billing Medicare carriers or fiscal intermediaries (FIs) for these vaccines
Provider Action Needed
Impact to You
Effective September 1, 2005, when payment is based on 95 percent of the AWP, the Medicare Part B payment allowance for the influenza virus vaccines are as follows: CPT 90655 is $14.678; 90656 is $15.818; 90657 is $6.028; 90658 is $12.056. Payment for the pneumococcal vaccine (CPT 90732) is $24.57 (when payment is based on 95 percent of the AWP).
What You Need to Know
Annual Part B deductible and coinsurance amounts do not apply to these vaccines. Also, remember that all physicians, non-physician practitioners, and suppliers who administer the influenza virus vaccination or the pneumococcal vaccination must take assignment on the claim for that vaccine.
What You Need to Do
Please take note of this pricing information to ensure accurate claims processing. Your carrier or FI will not search their files to adjust claims that were processed prior to the November 21, 2005, implementation date unless you bring such claims to their attention.
Additional Information
The official instructions issued to your carrier/intermediary regarding this change can be found at http://www.cms.hhs.gov/Transmittals/  on the CMS Web site. On the above page, scroll down while referring to the CR NUM column on the right to find the link for CR4109. Click on the link to open and view the files for the CR.
If you have questions regarding this issue you may also contact your carrier or FI at their toll-free number, which may be found at http://www.cms.hhs.gov/MedlearnProducts/downloads/CallCenterTollNumDirectory.pdf on the CMS Web site.
Disclaimer
This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents.
Medlearn Matters Number: MM4109
Related Change Request (CR) #: 4109
Related CR Release Date: October 21, 2005
Effective Date: September 1, 2005
Related CR Transmittal #: 185
Implementation Date: November 21, 2005
Posted: 11/30/2005
CPT codes, descriptions, and
other data only are copyright 2005 American Medical Association
(or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS Apply.
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